The addictive effect of opioids

The issue of opioid drug use and its abuse has become a major topic of discussion at both the national and local levels, and for good reason.

According to the Centers for Disease Control and Prevention, drug overdose deaths and opioid-involved deaths continue to increase in the U.S., with the majority of drug overdose deaths — more than six out of 10 — involving an opioid.

Since 1999, the number of overdose deaths involving opioids, which includes prescription opioids and heroin, quadrupled. From 2000-15, more than a half-million people died from drug overdoses. Ninety-one Americans die every day from an opioid overdose.

To help shed some light on opiate addiction and what leads to it, we talked to Dr. Jed Magen, a Michigan State University professor who specializes in the psychological effects of opioid use. The psychiatrist said the opiate issue is a combination of what starts as legal use and people who go directly to illegal use.

“A number of years ago, pain was defined as another ‘vital sign,’ and hospitals and practitioners were urged to pay attention to pain and treat it vigorously,” Magen said. “All this was done with the best of intentions.”

Added to this, he said, was that pharmaceutical companies began to see a market here for pain medications, and began to develop more short- and long-term opiates to treat this emerging market. According to Magen, the impression of many people based on some research was that patients who had pain did not develop dependency to what were known to otherwise be quite addictive medications.

“So physicians were encouraged to treat with opiates on the mistaken presumption that they did not have to worry about addiction with these people,” the professor said. “Of course, it turned out that substantial numbers of people treated with whatever opiate went on to develop dependency.”

According to Magen, if people tried to cut down or stop, they developed withdrawal symptoms.

“Two other phenomena also became important,” Magen said. “One is that, over time, humans ‘habituate’ to these drugs and so one needs a higher dose over time to get the same pain relief. So, doses generally got higher over time.

“The other issue is that if you have pain and you get analgesia at least for a while, you can no longer monitor if what you are doing might make the issue that caused the pain worse,” he said.

For example, Magen said that if you have back problems, now you have a lot less pain, so you do more and hurt yourself without realizing it. This, he noted, can cause more pain in the future.

“Once you develop dependency and begin to have a need for higher and higher doses, now you probably begin to take the dose that you have more frequently to get that higher dosage level, and now you run out of pills before it is time for a refill,” he said.

This, Magen noted, causes a person to develop withdrawal symptoms, which can be unpleasant and difficult to tolerate.

“Now you have a choice — go back to your physician and ask for more pills and admit that you are taking more than prescribed, begin to ‘doctor shop’ and see if you get pills from more than one physician, or go out on the street and see what you can get,” Magen said. “Substances like heroin and fentanyl are readily available and cheaper than going to your physician and pharmacy. They are often more potent, too.”

Magen explained that fentanyl is many times more potent than heroin, and it is easy for people to develop dependency, escalate use and then go on the streets for pills or heroin or other substances.

“There are some people who do use opiates for pain and use them appropriately and without getting into trouble,” he said. “It is not clear how to figure out who is at risk and who is not, though.”

In terms of what makes these drugs addictive, Magen said one has to talk about neurobiology.

“The short explanation is all drugs of abuse elevate a neurotransmitter called dopamine in an area of the brain called the nucleus accumbens,” he explained. “This is the so-called ‘pleasure center.’”

Magen said that anything that causes someone pleasure elevates dopamine in this area of the brain.

“Drugs of abuse do it faster and to a greater extent, so people get euphoric,” he said. “That gets them going back for more. And then once they get withdrawal symptoms, they have to get more.”

Eventually, people don’t get the euphoria, but have an increased need for the substance because they need more to kill the pain. They habituate to that and they are just chasing the withdrawal, according to Magen.

“Long-term addicts will tell you they are tired of taking heroin or whatever, but can’t stop,” he said.